Skeletal Metastases In Patients Research Articles

Can a fast T2-Dixon sequence surpass the time obstacle of whole-body MRI in the evaluation of skeletal metastases?

BackgroundWhole-body magnetic resonance imaging (WB-MRI) has shown its accuracy in the diagnosis of skeletal metastases in patients with known primary solid cancers. The standard protocol was a combination of T1 and short tau inversion recovery (STIR) sequences. Herein, this study was conducted to elucidate the role of the T2-Dixon sequence as a rapid alternative to the standard protocol with the assessment of its diagnostic accuracy and comparability to the established methodology.MethodsThis prospective study included 30 patients with primary solid malignancies who underwent WB-MRI. The sequences obtained were T1WI, STIR, and T2-Dixon (fat-only and water-only images). Skeletal metastases were evaluated in each sequence. Results were compared between the T1-STIR combination and T2-Dixon fat and water reconstructions.ResultsThe sensitivity of fat and water reconstructions from a single T2-Dixon in the detection of lytic skeletal metastases was marginally superior to a combination of T1WI and STIR sequences (0–7%). Detection of mixed lesions demonstrated equally high sensitivity in both protocols. Sclerotic metastases detection in WB-MRI showed low sensitivity in both protocols. However, specificity surpassed 95% for all lesion types in both protocols. Overall image quality was favored (in 87–90% of patients) in T2-Dixon images. The overall estimated acquisition timing using T2-Dixon appeared to be approximately half that of the standard T1-STIR combination.ConclusionsWB-MRI using T2-Dixon fat and water reconstructions showed similar accuracy to T1WI and STIR combination in the evaluation of skeletal metastases in patients with primary solid cancers with significantly shorter acquisition time.

Intra-individual comparison of 18F-sodium fluoride PET–CT and 99mTc bone scintigraphy with SPECT in patients with prostate cancer or breast cancer at high risk for skeletal metastases (MITNEC-A1): a multicentre, phase 3 trial

Detection of skeletal metastases in patients with prostate cancer or breast cancer remains a major clinical challenge. We aimed to compare the diagnostic performance of 99mTc-methylene diphosphonate (99mTc-MDP) single-photon emission CT (SPECT) and 18F-sodium fluoride (18F-NaF) PET-CT for the detection of osseous metastases in patients with high-risk prostate or breast cancer. MITNEC-A1 was a prospective, multicentre, single-cohort, phase 3 trial conducted in ten hospitals across Canada. Patients aged 18 years or older with breast or prostate cancer with a WHO performance status of 0-2 and with high risk or clinical suspicion for bone metastasis, but without previously documented bone involvement, were eligible. 18F-NaF PET-CT and 99mTc-MDP SPECT were done within 14 days of each other for each participant. Two independent reviewers interpreted each modality without knowledge of other imaging findings. The primary endpoint was the overall accuracy of 99mTc-MDP SPECT and 18F-NaF PET-CT scans for the detection of bone metastases in the per-protocol population. A combination of histopathological, clinical, and imaging follow-up for up to 24 months was used as the reference standard to assess the imaging results. Safety was assessed in all enrolled participants. This study is registered with ClinicalTrials.gov, NCT01930812, and is complete. Between July 11, 2014, and March 3, 2017, 290 patients were screened, 288 of whom were enrolled (64 participants with breast cancer and 224 with prostate cancer). 261 participants underwent both 18F-NaF PET-CT and 99mTc-MDP SPECT and completed the required follow-up for statistical analysis. Median follow-up was 735 days (IQR 727-750). Based on the reference methods used, 109 (42%) of 261 patients had bone metastases. In the patient-based analysis, 18F-NaF PET-CT was more accurate than 99mTc-MDP SPECT (84·3% [95% CI 79·9-88·7] vs 77·4% [72·3-82·5], difference 6·9% [95% CI 1·3-12·5]; p=0·016). No adverse events were reported for the 288 patients recruited. 18F-NaF has the potential to displace 99mTc-MDP as the bone imaging radiopharmaceutical of choice in patients with high-risk prostate or breast cancer. Canadian Institutes of Health Research.

Hybrid Ga-68 prostate-specific membrane antigen PET/MRI in the detection of skeletal metastasis in patients with newly diagnosed prostate cancer: Contribution of each part to the diagnostic performance.

Bone metastasis is essential in patients with prostate cancer (PCa) as it determines prognosis and survival. Hybrid PET/MRI allows simultaneous acquisition of PET and MRI data, thus combining the strength of both technologies allows the detection of bone marrow metastases that are missed by PET/CT. In this retrospective study, we aimed to evaluate the diagnostic efficiency of hybrid PET/MRI with Ga-68 prostate-specific membrane antigen (PSMA) in detecting skeletal metastases in newly diagnosed PCa patients and compared the effectiveness of stand-alone PSMA PET reviewing versus stand-alone whole-body (WB) MRI evaluation. We also investigated the effect of the interpretation of all PET/MR data together on clinical management. We studied 74 newly diagnosed PCa patients who underwent PSMA PET/MRI for staging purposes. At first, PET and MRI were evaluated separately for bone lesions on a patient-and-lesion basis and then a further joint PSMA PET/MRI interpretation was made. Patient-based sensitivity, specificity, positive predictive value, negative predictive value and accuracy analysis for bone metastasis was, respectively, 1.0, 0.83, 0.54, 1.0, 0.86 for PET; 0.75, 0.96, 0.81, 0.95, 0.93 for WB MRI and 0.91, 0.95, 0.78, 0,98, 0.94 for PET/MRI. The combined PET/MRI evaluation changed the clinical impact in 13.5% of patients (eight correct and two wrong decisions) compared to PET stand-alone interpretation. PSMA PET imaging showed superior sensitivity to WB MRI in detecting bone metastases in newly diagnosed PCa patients, whereas WB MRI has superior specificity and PPV. Furthermore, the specificity and PPV of joint PET/MRI evaluation are better than PSMA PET alone. Despite the longer acquisition period, adding WB MRI sequences to PSMA PET imaging appears beneficial for PCa patient management.

What's New in Musculoskeletal Tumor Surgery.

What's New in Musculoskeletal Tumor Surgery.

Bone Scintigraphy Metastatic Patterns in Patient with Prostate Cancer at Ocean Road Cancer Institute

Objectives: Prostate cancer is the second most common malignancy in the world next to lung cancer and it is the leading cause of morbidity and mortality among men. The most common metastatic site in prostate cancer is the bone. This study is aiming at finding the pattern and frequency of bone metastasis among prostate cancer patients at Ocean Road Cancer Institute, Tanzania. Methods: This was a cross section retrospective hospital based descriptive study involving 139 patients with prostate cancer who were seen from June 2014 to June 2016 whose bone scan were reviewed. Results: Bone metastases were found in 77 patients (55.4%) The prevalence was higher in the age group between 60 and 79 (56.3%) however there was no statistical significance between age and occurrence of bone metastasis. Patient who had high PSA level and Gleason score had more occurrence of skeletal metastasis. Spine was the most common site for bone metastasis constituting 72 patients (51.8%) of all the patients followed by ribs metastasis (31.7%), Also it was shown that of the spine metastasis, lumbar spine was more frequent affected (48.2%) followed by thoracic and cervical spine (41.0% and 27.3% respectively) Conclusion: The prevalence of skeletal metastasis in patients with Prostate cancer at Ocean Road Cancer Institute was high (55.4%). The prevalence was higher in patients with PSA level more than 20 and those with Gleason score of more than 7. Spine was the commonest site for metastasis and of the spine, metastasis lumbar spine metastasis was most frequent site. Recommendations: It is recommended that bone scan should be done as baseline in patients with prostate cancer particularly those with PSA level more than 20ng/ml and Gleason score of more than seven.

Pattern of Skeletal Metastasis in Breast Cancer Patients Attending INMAS, Rajshahi

Breast cancer is the most common malignant tumor of females, the incidence increases with age. Bone is the most common site to which breast cancer metastasizes. Between 30% to 85% of patients with metastatic breast cancer develop bone metastases during the course of the disease. Bone scan is the most commonly used means of detecting bone metastasis; it visualizes increases in osteoblastic activity and skeletal vascularity. Many radio-pharmaceuticals (radionuclides) have been used in bone scan including technetium-99m bound to methylene diphosphonate (MDP). Published sensitivity and specificity rates of bone scan for diagnosis varies, with sensitivity ranging from 62% to 100% and specificity from 78% to 100%. However, bone scan is generally considered sensitive for detecting bone metastases on whole-body images.The aim of this study was to evaluate the pattern of distribution of skeletal metastases in patients with breast carcinoma by using Tc-99m MDP bone scan. A retrospective study was conducted on 245 consecutive female breast carcinoma patients irrespective of clinical staging, menopausal status and pre-operative / post- mastectomy status, referred for bone scan to Institute of Nuclear Medicine and Allied Sciences, Rajshahi from July 2015 to June 2017. The mean age of the patients was 43.4 ± 13.8 years (mean ± SD) with range from 29 to 66 years. Bone scan was performed by an intravenous bolus injection of 20 mCi Tc99m-MDP. Bone phase images were taken at three hours after injection of the radiotracer. Out of 245 studied patients, 163 patients (66.53%) were negative for skeletal metastasis and 82 patients (33.47%) were positive for skeletal metastasis. Out of 82 patients with positive skeletal metastasis, 68 (82.93%) patients had multiple sites (two or more) and 14 (17.07%) patients had solitary site of bony involvement. Out of 68 patients with multiple sites of skeletal metastasis, highest number was noted in thoraco-lumbar spine (80.89%), followed by ribs including sternum and clavicle (57.35%), pelvic bones (47.06%), upper extremities including scapula (41.18%), lower extremities (33.82%), cervical spine (23.53%) and skull bone (8.82%). Among 14 patients with solitary skeletal metastasis, maximum number was noted in thoraco-lumbar spine (64.29%), followed by cervical spine (14.29%), pelvic bone (07.14%), ribs (07.14%) and sternum (07.14%). Skeletal metastases were much more common in multiple sites than solitary lesion in breast cancer patients. Thoraco-lumbar spine was the most common site of involvement in both solitary and multiple lesions in our study. Axial skeleton was more commonly involved than the appendicular skeleton. Bone scan may pick up bone metastases up to 18 months earlier than conventional radiology, with an average lead of four months. 99m Tc- MDP bone scan is very cost effective in comparison to other imaging modalities (CT, MRI, and PET) and play a major role in early detection of skeletal metastasis in breast cancer patients.
 Bangladesh J. Nuclear Med. 21(1): 21-25, January 2018

CAPABILITIES OF MAGNETIC RESONANCE IMAGING IN THE DETECTION OF METASTATIC LESION OF THE SPINE AND PELVIC BONES IN PATIENTS WITH PERIPHERAL NON-SMALL CELL LUNG CANCER

Objective. To comparatively analyze the diagnostic capabilities of magnetic resonance imaging (MRI) of the spine and pelvic bones with the results of 18F-FDG positron emission computed tomography (PET/CT) and single-photon emission computed tomography (SPECT/CT) in the detection of skeletal metastases in patients with peripheral non-small cell lung cancer (PNSCLC) in order to elaborate optimal approaches to using radiation and nuclear diagnostic techniques. Material and methods. Seventy-one patients with PNSCLC underwent a comprehensive examination of the skeleton regardless of whether they had clinical symptoms of bone lesions. MRI of the spine and pelvic bones, 18F-FDG PET/CT, and SPECT/CT were performed in all the patients with PNSCLC. The investigators analyzed MRI changes in different skeletal parts (cervical, thoracic, lumbar spine, sacrum and pelvic bones) in patients with PNSCLC and compared the findings with the results of a set of radiation and nuclear diagnostic techniques (18F-FDG PET/CT, SPECT/CT). The sensitivity, specificity and diagnostic accuracy of imaging techniques were compared. Clinical cases are presented. Results. 18F-FDG PET/CT is superior to MRI for the detection of metastatic lesions of the spine and pelvic bones. The sensitivity, specificity, and diagnostic accuracy of MRI for the identification of metastases in the spine and pelvic bones were 95.65, 96.8, and 95.85%, respectively. Those of 18F-FDG PET/CT in the detection of bone metastases were 98.7, 99.9, and 99.6%, respectively. Conclusion. 18F-FDG PET/CT is indicated for all patients with PNSCLC to rule out skeletal metastases. It is expedient to perform MRI if there are technical problems with 18F-FDG PET/CT for the detection of metastatic lesion of the spine and pelvic bones.

Role of Whole-Body Tc 99m MDP Bone Scintigraphy for Evaluating Skeletal Metastasis in Patients with Lung Cancer

Lung cancer is the third most common site of origin of metastatic cancer deposits in bone, after breast and prostate. It’s metastasis to bone is one of the most aggressive tumors and has a very unfavorable prognosis. This retrospective descriptive study was designed to detect the skeletal metastasis of carcinoma (Ca) lung patient by Tc 99m MDP bone scan. The medical records of all patients attended between January 2015 and July 2015 with a diagnosis of lung cancer were reviewed. Lung cancer in all patients was confirmed pathologically, and patients underwent whole-body bone scan for evaluating skeletal metastasis. Patient with clinical and laboratory evidence of infection, trauma, metabolic disease or arthropathy were not included in the study. Bone scan was done after three hours of intravenous administration of 20mci Tc 99m MDP (methylene diphosphonate) and images were obtained on a gamma camera. The mean age of the patients was Mean ± SD was 55.5 ± 12.5 with range from 31 to 90 years. Out of 47 cases, 36 (76.59%) were diagnosed as positive for skeletal metastasis by bone scan and 11 (23.41%) were negative for bony metastasis. Among 36 positive patients, 28 patients (77.86%) were histopathologically diagnosed as adenocarcinoma, 7 patients (19.44%) had squamous cell carcinoma and only one patient (2,7%) had small cell carcinoma. Bone scan findings were compared by either conventional X-ray/CT scan/MRI /pathologically. In present study, the distribution of lesions in bone scan had recorded. Maximum 47.22 % lesions were found in ribs, 27.77% lesions were in lumbar vertebrae, 19.44% in thoracic vertebrae, 19.44% in joints, 16.66% in long bones (femur and humerus), 11.11% in skull bones, 22.22% in pelvic bones, 5.55% in clavicle and 2.77% in scapula. Tc 99m MDP bone scan plays a pivotal role for detection of skeletal metastasis which is very essential to manage Ca lung patient. As bone scintigraphy is very cost effective in govt. nuclear medicine centre in comparison to other imaging modalities, so it can play a major role in detecting skeletal metastasis in ca lung patients in a developing country like Bangladesh.

Longitudinal Computed Tomography Monitoring of Pelvic Bones in Patients With Breast Cancer Using Automated Bone Subtraction Software

The aim of this study was to optimize computed tomography (CT) surveillance of skeletal metastases in patients with breast cancer through the use of osseous subtraction maps between baseline and follow-up examinations created by a novel software algorithm. The new postprocessing algorithm segments the original bone followed by image intensity-based rigid alignment creating gray-shaded maps that highlight focal or diffuse loss or increase in bone attenuation. Institutional review board was obtained for this retrospective data evaluation. A total of 33 consecutive patients (31 female; 2 male; mean age, 59.13 ± 12.68 years; range, 32-81 years) with breast cancer were included, who underwent 143 standardized baseline and follow-up CT examinations between February 2014 and June 2016. We classified bone metastases into lytic, sclerotic, and mixed osseous lesions. Any new osteolysis inside a known sclerotic lesion and enlargement of pre-existing sclerotic lesions were considered to represent progressive disease (PD), whereas no change was classified as stable disease (SD). Results were compared additionally with the course of the disease considering the entire skeleton and other involved organs. Software-created automated bone subtraction maps were compared with conventional CT interpretations of axial 5-mm and coronal 1-mm reformatted images. Region of interest measurements were used to quantify new lesions. Results were validated by clinical and CT follow-up. Reading time was evaluated. Skeletal metastases were present in 17/33 (51%) patients (9 sclerotic, 2 lytic, 6 mixed) at baseline. The use of bone subtraction maps resulted in an overall change of response classification into PD in 9/33 (8.1%) patients. Compared with conventional CT evaluation, the bone subtraction maps disclosed 123 new or enlarging sclerotic and 32 new lytic metastases in 23/33 (30.9%) examinations. Mean attenuation of new bone lesions (sclerotic or lytic) significantly increased or decreased (P < 0.01) in all patients. Bone attenuation in pelvic areas without evident metastatic disease significantly increased in patients with PD (P = 0.019), whereas there was no change in SD (P = 0.076). Lesion-based sensitivity, specificity, accuracy, positive predictive values, and negative predictive values were 98.7%, 79.5%, 94.5%, 95.1%, and 94.5%, respectively. Interobserver agreement was good (κ = 0.80; P = 0.077). Reading time was significantly faster for the bone subtraction maps versus 5-mm axial images (P < 0.001). Longitudinal bone subtraction maps increase the accuracy and efficiency of CT diagnosis of skeletal metastases in patients with breast cancer.

Study of distribution of bone metastases in metastatic breast cancer patients compared to other major cancers

Introduction: Metastatic bone disease is frequent in patients with advanced breast cancer. Although it is not specific for the detection of metastatic bony lesions, bone scan is a sensitive method. The pattern of distribution of bone metastases as detected by bone scan combined with clinical data may help in reaching diagnosis. Methods: Technetium-99m-methylene diphosphonate skeletal scintigraphy was used for evaluation of distribution pattern of skeletal metastases in patients with breast carcinoma compared to other common cancers. Results: Out of 134 patients with positive bone scan for skeletal deposits, the primary cancer was breast cancer in 81 patients, prostate in 24, lung in 12, liver in 8, urinary bladder in 6, and head and neck in 3. Few metastases (≤ 3 deposits) were common in breast cancer, while extensive metastatic lesions (≥10 deposits) were more common in prostate cancer (50%). The most common locations of bone metastases in patients with breast cancer were the spine, pelvic bones, femora, and ribs, respectively. In prostate cancer patients, spine was the most common site of metastases, especially the lumber region. In lung cancer patients, thoracic spine was the most common site of metastases, while pelvic bones were the most common site in liver cancer patients. Conclusion: In breast cancer, the most frequent sites of involvement are the spine (especially lumber region), pelvis and axial skeleton, respectively. Spinal and sternal involvements are significantly more in breast cancer than in other malignancies.

Survival analysis in patients with metastatic spinal disease: the influence of surgery, histology, clinical and neurologic status.

Spine is the most common site for skeletal metastasis in patients with malignancy. Vertebral involvement quantification, neurological status, general health status and primary tumor histology are factors to set surgical planning and therapeutic targets. We evaluated the impact of general clinical and neurological status, histologic type and surgery in survival. The study sample consisted of consecutive patients admitted from July 2010 to January 2013 for treatment. Sixty eight patients were evaluated. 23 were female and 45 were male. Main primary neoplasic sites were: breast, prostate, lung/pleura and linfoproliferative. Thirty three out of 68 received surgical treatment, 2 received percutaneous biopsy and 33 had nonsurgical treatment. Log Rank curves revealed no statistical significant difference according to histological type, surgical approach and Frankel Score. Karnofsky Score was statistically different. Histological type and clinical status were statistically associated with life expectancy in vertebral metastatic disease.

Effect of oral bisphosphonates for osteoporosis on development of skeletal metastases in women with breast cancer: results from a pharmaco-epidemiological study.

Treatment with bisphosphonates in women with breast cancer and established bone metastasis delays further skeletal-related events. Evidence is emerging that bisphosphonates are beneficial for secondary prevention of bone metastasis. The study aimed to estimate the effect of oral bisphosphonates for treatment or prevention of osteoporosis on development of bone metastasis in a population of women with breast cancer. A historical cohort of 21664 women diagnosed with breast cancer was created from health administrative data in Quebec, Canada. The primary outcome was time to develop bone metastasis; exposure was bisphosphonate use prediagnosis, postdiagnosis, both, or neither and a cumulative index of drug exposure. The sample was stratified according to stage (0-II or III) at time of diagnosis. Cox proportional hazards tested the effect of bisphosphonate use on time to develop bone metastases. Taking bisphosphonates postdiagnosis of breast cancer only or continuing bisphosphonates started prior to diagnosis after diagnosis was associated with a reduction in risk of bone metastasis from 45% to 28% in women with local disease at diagnosis. In women with regional disease, postdiagnosis bisphosphonate use, with or without prediagnosis use, reduced risk by almost 50%. A statistically significant dose-response trend was observed relating increased use to lower risk (slope = 0.94, 95% confidence interval = 0.90 to 0.99). Bisphosphonates were also associated with a decreased risk of all-cause mortality similar to that of the development of bone metastasis. Low-dose oral bisphosphonates administered for prevention or treatment of postmenopausal osteoporosis were associated with lower risk of skeletal metastasis in patients with early- or more advanced-stage breast cancer.

Is femoral uptake of Tc99m-methylene diphosphonate on bone scintigraphy in bronchogenic carcinoma an alarming sign: A case report and brief review of literature?

Detection of skeletal metastasis in patients with lung cancer is important from management point of view. We report the bone scan finding in a patient with non-small cell lung carcinoma showing isolated abnormal tracer in femur and having a characteristic appearance in computed tomography, highlighting the importance of bone scan in patients with bronchogenic carcinoma.

A Comparative Study between Whole Body Magnetic Resonance Imaging and Bone Scintgraphy in Detection of Bone Metastases in Patients with Known Breast or Lung Cancer

Purpose: The aim of this work is to compare the ability of whole body MRI including diffusion study with that of 99m Tc-Methylene Diphosphonate Scintigraphy to detected skeletal metastases in patients with breast and lung cancer. Patients and methods: 60 patients comprising 38 females and 22 males ranging in age from 30 to 60 years with a mean age of 48.1 years (mean age 47.3 years for females and 49 years for males) were enrolled in the study. 29 females are histopathologically proven cases of breast malignancy, 9 females and the 22 males are histopathologically proven cases of lung cancer. The patients were referred from Oncological departments to perform the whole body MR study and bone scan at Ain Shams University hospitals MRI units and a private center during the time interval from December 2008 till December 2012. All patients were subjected to both whole body MRI and bone scintigraphy. The whole body MRI was mainly obtained using 4 contiguous coronal stations for body coverage using the body coil and 2 contiguous sagittal stations for the spine using T1W FSE and STIR sequences. 48 out of 60 patients toke IV contrast and post contrast T1W imagaes with fat suppression were taken. The MRI examinations were performed using a superconducting 1.5 Tesla magnet (Achieva: Philips Medical Systems). Standard skeletal Scintigraphy was performed using a planar one phase technique (delayed phase). The examination was done 2-3 hours after IV injection of technicium 99m labeled Methylene Diphosphonate with a maximum dose of 20 mCi. Results: 42 patients out of 60 were positive for metastases based on histopathological verification or follow up. On MRI, 39 patients had metastases, 3 were false negative, 12 were true negative and 6 were false positive. On bone scan, 35 were true positive, 7 were false negative, 4 were false positive and 14 were true negative. Based on lesion detection, on comparing bone scan to WB-MRI with and without diffusion, bone scan had an overall sensitivity of 85.6%, specificity 67.5 %, PPV 61.7% and NPV 66.3%, while WB-MRI had statistical values of 73.4%, 68.8%, 78.1% and 62.6% respectively. On adding DWI, values raised to 88.9%, 82.9%, 93% and 69% respectively. Quantitative analysis of DWI was also included in this study revealing an overlap between the Low ADC values of red marrow and metastasis at the range of 0.61 to 0.69 x10-3 mm2/sec and then between metastasis and other benign pathological marrow entities at the range of 0.9 to 1.03 x 10-3 mm2/sec. WB-MRI also detected 64 soft tissue metastatic lesions which became 71 lesions on adding DWI with a distribution of hepatic, pulmonary, brain, adrenal, lymph nodes, pleural, leptomeningeal and renal lesions. Conclusion: we don't think that WB-MRI should replace bone scan in the quest for skeletal metastases. However, we believe that WB-MRI should be the modality of choice when both skeletal and soft tissue metastases are suspected and in the follow up of a known metastatic patients for adequate coverage of both skeletal and soft tissue structures combined with qualitative and quantitative features of DWI helping assess tumors at cellular levels even prior to gross morphological changes verifying response to therapy as early as possible sparing patients precious time from drifting with delayed decision making.

Extraosseous uptake of technetium-99m methylene diphosphonate by an acute territorial cerebral infarct in a classical biodistribution pattern

Technetium-99m methylene diphosphonate scintigraphy is usually performed to assess bone lesions, especially skeletal metastases in patients with a history of malignancy. However, it is important to recognize some specific conditions with a unique pattern of tracer uptake, especially in extraosseous locations as they are not related to primary neoplasm or metastases. Diagnosing such unusual presentation is essential as it significantly influences the clinical management. This case report describes an unusual presentation detected in a bone scan of an elderly female patient, who was a treated case of breast cancer and was referred for a bone scan to rule out bone metastases. Incidentally, a large acute territorial cerebral infarct was diagnosed, which was later confirmed by magnetic resonance imaging on diffusion-weighted images. Diagnosis of the typical presentation and timely management saved the patient life.

P2-059 - Skeletal Complications and Survival in Gastric Cancer Patients with Skeletal Metastases

ABSTRACT Background The skeleton is one of the most frequent sites for metastases in patients with advanced cancer. Several guidelines have been proposed covering diagnosis and management of skeletal metastases in patients with breast and prostate cancer. As skeletal metastases in gastric cancer are less frequent events, there have been limited reports that evaluated the incidence, influence on survival of skeletal metastases and the role of bisphosphonate in the treatment of advanced gastric cancer. Material and methods Between 2002 and 2011, we retrospectively reviewed the medical records of 138 patients with metastatic gastric cancer in our institute. We investigated incidence of skeletal metastases, percentage of patients who developed skeletal-related events (SREs) and differences in the therapeutic outcome between patients with and without skeletal metastases. Results Of the 138 patients, 23 patients (median age: 59.5 years; ranged from 29 to 76) were found to have skeletal metastases during their clinical course. Almost all patients have multiple sites of disease that appeared osteoblastic on radiography. Among them, only three (13%) patients experienced SREs (two had spinal cord compression and one had pathological fracture), because most of the patients died of systemic disease progression before the clinical development of SREs. Of the 23 patients, 18 patients (78.3%) had skeletal metastases at the time of initial diagnosis, and 5 patients (21.7%) developed skeletal metastases later in the course of their disease. For 18 patients who presented skeletal metastases at the diagnosis, the median survival time (MST) was 7.4 months, whereas it was 11 months for those without such metastases. Hematological complications, including microangiopathic hemolytic anemia (MAHA) and disseminated intravascular coagulation (DIC), occurred more often with skeletal metastases than with non-skeletal metastases (44 versus 0.9%, respectively), which may relate to the shorter survival of patients with skeletal metastases. Conclusions Our study suggests that the prognosis of gastric cancer with skeletal metastases is poor. Earlier identification and the novel treatment of skeletal metastases would be crucial for improving survival in this patient group.

Oral bisphosphonate use in the elderly is not associated with acute kidney injury

Intravenous bisphosphonates can cause acute kidney injury; however, this risk was not found with oral bisphosphonates in randomized clinical trials with restrictive eligibility criteria. In order to provide complementary safety data, we studied the risk of acute kidney injury in a population-based cohort of 122,727 patients aged 66 years and older discharged from hospital following a new fragility fracture and no history of bisphosphonate use in the prior year. Bisphosphonate treatment was identified within 120 days after discharge and event rates were measured from 90 days of therapy initiation. The primary outcome was hospitalization with acute kidney injury with secondary outcomes of new nephrology consultation and, in a subset of patients with laboratory values, acute kidney injury was defined as an increase in serum creatinine. We identified 18,286 bisphosphonate users and 104,441 non-users with a mean age of 81 years. Of 5772 patients with laboratory values, 40% had chronic kidney disease (eGFR <60 ml/min per 1.73 m(2)). Overall, there was no statistically significant difference in the risk of acute kidney injury among bisphosphonate users compared to non-users (adjusted odds ratio 1.03), and no significant differences in other outcomes or in subgroups of patients with baseline chronic kidney disease. Thus, in this older population-based cohort, oral bisphosphonate use was not associated with acute kidney injury.

Meme kanserli bir hastada 18-Floro-de-oksi-Glukoz pozitron emisyon tomografisinde multiple kemik metastazları: Olgu sunumu ve literatürün gözden geçirilmesi [Multiple bone metastases detected on 2-[18F]-fluoro-2-deoxy-d-glucose PET

Bone scintigraphy has been widely used to assess skeletal metastasis in patients with breast cancer. 18F-FDG-PET/CT is another imaging modality that has gained previously wide use to determine metastasis based on increased glucose metabolism in malignant cells. Generally, these two modalities give similar results in evaluation of bone metastasis of breast cancer. In this breast cancer case, 99mTc-MDP bone scintigraphy showed normal findings in regards to skeletal metastasis while 18F-FDG-PET/CT, contrast-enhanced CT and MRI revealed multiple metastatic focuses.

Is bone scintigraphy indicated in surgical work-up for hepatocellular carcinoma patients?

BackgroundPatients with hepatocellular carcinoma (HCC) undergo extensive staging investigations when being assessed for surgical resection. The aim of this study was to assess the use and yield of baseline bone scintigraphy in patients with HCC necessitating high-risk surgical resection. Material and methodsAll patients diagnosed with HCC between 2000 and 2010 within a tertiary referral center were reviewed. Recurrence and survival rates were compared between patients with and without bone scintigraphy in their preoperative work-up. ResultsA total of 366 patients were diagnosed with resectable HCC. In the work-up for resection 137 HCC patients (41%) underwent bone scintigraphy, which showed bone metastases in 3 (2%). There was no significant difference in long-term survival between patients with and without bone scintigraphy. None of the patients with a positive bone scintigraphy died due to skeletal bone metastases. Only one patient had an indication for bone scintigraphy based on clinical suspicion. Two patients were found to have asymptomatic skeletal metastases prior to surgery. Symptomatic skeletal metastases were identified at an estimated cost of €27,008 per case. ConclusionsClinically unsuspicious bone lesions turned out to be metastases in two patients, with an estimated cost of €27,008 per case. Recurrence rate and disease-free and overall survival showed no significant difference between patients with and without preoperative baseline bone scintigraphy. There is no justification for routine preoperative bone scintigraphy to detect asymptomatic skeletal metastases in patients with resectable HCC.

Positron emission tomography/computed tomography imaging of brown tumors mimicking multiple skeletal metastases in patient with primary hyperparathyroidism

Brown tumors of bone are highly vascular, lytic bone lesions representing a reparative cellular process rather than a neoplastic process usually seen in patients with hyperparathyroidism. These tumors can behave aggressively and be destructive. We report a 49-year-old male patient who was admitted to our hospital with a long-term history of right shoulder and right hip pain. Multiple lytic and destructive bone lesions were found in X-ray graphy and CT images. These bone lesions mimicked multiple skeletal metastatic lesions and seemed to be those of the terminal stage of malignancy. PET scan was requested for the evaluation of FDG uptake of these lesions and to search the unknown primary tumor site. Positron emission tomography/computed tomography (PET/CT) images showed multiple hypermetabolic malignant or metastatic FDG avid bone lesions in skeletal system. However the biopsy results revealed no signs of malignancy and laboratory data showed elevated serum calcium, alkaline phosphatase, parathyroid hormone, low serum phosphate and parathyroid scintigraphy was performed. Adenoma in the left parathyroid gland was seen with Tc-99m MIBI parathyroid scintigraphy. Pathological results confirmed the diagnosis of parathyroid adenoma. Brown tumor is the potential cause of false-positive result in evaluation of a patient for unknown primary tumor or skeletal metastases with PET/CT imaging.